Opioid Use in Middle Eastern Countries in Comparison to the United States Status Quotextarticle2010engMorphine is one of the more ancient medicines known, yet the global access to this opioid is still severelylimited. In spite of the fact that strong networks for national, regional and global care have been emerging, theoverall situation of pain management, in general, and in cancer patients in specific, remains of great concern;when we examine the availability of pain relief drugs in Middle Eastern countries. The data presented in thisabstract rely on the INCB annual reports. Consumption of Morphine. In the USA the consumption is on the riseand has reached over 76 mg/capita in the year 2007 (the global mean is 5.57 mg/capita). In Israel the consumptionof morphine in 2007 is similar to that in 2004, a little above 3.0 mg/capita. In Cyprus during the year 2004-2007the consumption was at about 2.8 mg/capita. In Jordan, morphine consumption has been on the rise since 2006and is at about 2.0 mg/capita. In Lebanon, morphine consumption has been at a steady state (1.0 mg/capita) forthe period 2004-2007. In Turkey, the consumption of morphine has been fluctuating at doses about 0.1 mg/capita fort the period 2004-2007. In Saudi Arabia, the consumption of morphine has been at very low doses ofabout 0.05 mg/capita for the same time period. In Egypt, the doss of consumption were fluctuating between0.01-0.14 mg/capita during the years 2004-2007. When comparing the quantities of consumption in the variousMiddle Eastern countries with that in the United States (in year 2007), it became apparent that in the USA theconsumption of morphine is: 10 times that in Israel; 27 times that in Cyprus; 38 times that in Jordan; 69 timesthat in Lebanon; 150 times that in Saudi Arabia; 447 times that in Turkey; 633 times that in Egypt. It is nowadaysclear that the medial use of opioid drugs is indispensable for the relief of pain and suffering; and most developingcountries use very small amounts of morphine.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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201015http://journal.waocp.org/article_25159_8af53ce0509b8962a61de46f05128110.pdfThe Global Experience of Cancer Paintextarticle2010engPain is a significant problem in patients with cancer. Pain occurs in approximately 50% of patients at somepoint during the disease process and in up to 75% of patients with advanced cancer. Total pain impacts qualityof life domains including physical, psychological, social, and spiritual realms. Unfortunately, pain isunderappreciated and undermanaged throughout the world. Lack of knowledge among healthcare professionals,inadequate pain assessment, fears of addiction, and beliefs that pain is an inevitable component of cancer arecommon barriers. Education about comprehensive pain assessment and optimal management strategies anddiscussions about belief systems regarding pain can assist to bridge the gap between suffering and comfort.Self-report is the gold standard for pain assessment. Gathering information about the location(s), intensity,quality and temporal factors is essential. Intensity should be quantified on a rating scale to determine theamount of pain and the degree of relief from interventions. Quality can be used to diagnose the specific painsyndrome. Temporal factors provide input about how the pain is experienced over time and can offer input intothe pain management plan of care. For patients who cannot self-report pain, non-verbal assessment tools areavailable to aid in assessment. The World Health Organization’s Analgesic Ladder provides a template for themanagement of cancer pain. For step 1, pain can be managed with nonsteroidal anti-inflammatory drugs(NSAIDS) and other nonopioid analgesics. As pain persists or increases, step 2 involves managing pain withselect opioids for mild to moderate pain along with NSAIDS and nonopioid analgesics. Step 3 of the ladder isapplicable to many cancer pain syndromes, and includes opioids for moderate to severe pain in conjunctionwith NSAIDS and nonopioids. This 3 step approach can be 80-90% effective. This polypharmaceutical employedwith behavioral complimentary techniques are often employed to interrupt pain along the physiological pathwaysduring transduction, transmission, perception, and modulation. Severe cancer pain that is not managed withthe Step 3 approach, deserves special attention and unique strategies for control. When pain control is inadequateor if side effects are intolerable, a change of opioid or a change in the route of administration is recommended.Intraspinal analgesics can be trialed in patients who have intractable pain or intolerable side effects with systemicopioids. This route is especially helpful in neuropathic pain syndromes located at the trunk level or below.Opioid doses in all patients with intractable pain should be titrated judiciously for optimal relief with a balanceof toxicity management. Other strategies for intractable pain should be investigated including nerve blocks andneuroablation. The overall goal for patients is to attain comfort with minimal side effects and optimal quality oflife.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010712http://journal.waocp.org/article_25160_16a967f2bad972273457f56dd7d667fb.pdfUsing Leadership and Advocacy to Improve Cancer Pain Management - Based on a Presentation at the Cancer Pain, Suffering and Spirituality Coursetextarticle2010engBeing a leader is not dependent on a title and, in fact, every oncology nurse is a clinical leader. Building onskills in caring for patients, oncology clinicians and nurses use their knowledge and skills to: advocate forpatients; initiate performance improvement projects; develop new services for patients and families; ensurequality and safety of care; influence health policy. Because of oncology clinicians and nurses’ closeness topatients and families in all settings, they know where the barriers to excellence are in organizations. This sessionwill provide an overview of leadership skills and how nurses in particular can use their expertise as clinicians toimprove the care delivery in their organizations and communities.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20101316http://journal.waocp.org/article_25161_d0ca03df9ce5e4b9f46b877222323182.pdfRegulatory Barriers for Adequate Pain Controltextarticle2010engIn 1961 the "Single Convention on Narcotic Drugs" was adopted by the United Nations to explicitly addressthe need for narcotic drugs to curtail suffering and keep the distribution of these drugs in the control of healthprofessionals. Fifty years later, neither goal has been reached for a variety of reasons. Governments haveavoided putting in place systems to assure adequate supplies to relieve the suffering of those with severe pain,drug enforcement agencies maintain restrictive regulations and physicians are intimidated by threats of legalaction if their prescribing patterns do not conform to arbitrary standards. There is a shortage of pain controlconsultants and the training for most health care providers is deficient when it comes to the management ofchronic pain. Some of the regulatory barriers have been successfully addressed through advocacy efforts andthe expertise deficiencies improved through targeted educational programs.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20101721http://journal.waocp.org/article_25162_72ef38bd88885a40d41846aa0a901139.pdfAdvanced Care Planning, Empowering Patients for a Peaceful Deathtextarticle2010engIn the early 1900’s, Americans had a life expectancy of about 50 years. Childhood mortality was very highand an adult who lived into their sixties was considered to be doing pretty well. Prior to the advent of differenttypes of antibiotics, people would die quickly of infectious disease or accidents and medicine only really focusedon caring and comfort. Since then, there has been a shift in medicine’s focus. New science, technology andcommunications have shifted the way Americans treat incurable diseases and have promoted the idea of aggressivefighting as well as to keep patients alive at any costs. The internet has allowed easy access for patients to do onlineresearch and to know the treatments for diseases and the availability of trials. This has promoted the ideathat every disease or cancer is curable if the patient does exactly as the internet says. It has hindered the idea ofcompassionate care and dying with dignity so that a patient can stay alive at all costs, even in a vegetative state.In the last two decades, there has been a significant expansion of palliative and supportive care services in theUnited States. This has including the development of a specialty for palliative care medicine with a boardcertification in hospice and palliative medicine. A challenge to the field has been the reluctance of physicians torequest palliative care consults in a very timely manner as well as relinquish care of their patients. A commonoccurrence in the United States, at many cancer centers, is the treatment of chemotherapy and radiation upuntil the day before a patient dies. At this point, the physician ends up throwing up his or her hands withnothing left to offer the patient or its family. However, what we have been finding is that presently there are nowmany oncologists who are willing to refer patients to palliative care for specific management of difficult paincontrol issues. At the Moffitt Cancer Center, we have a Palliative Care consulting service along with a PalliativeCare Fellowship program where we work with cancer teams to provide resources to them when they are runninginto difficulties with their patients. Typically, we step in when first line treatments have failed, symptoms haveshown no signs of decrease, or when the primary teams have exhausted their standard management options.Our hope is for the primary care teams to be able to manage basic symptoms themselves and only call on thePalliative Care team when they have surpassed their comfort zone. For example, the Palliative Care teamwould step in if a patient’s dosage of medication was out of a primary team’s spectrum. Other uses of thePalliative Care team include having the end of life discussion with the patients to find out what their expectationsare of their treatment, what their concerns are and what their requests are. Normally treating primary teamsare very uncomfortable in having this discussion with their patients due to the feeling that they are giving uphope or the fact that they are letting patients know that the end of the road is near. The Palliative Care team canthen be called upon to come in and transfer the care from the primary team to the "death team". At Moffitt wehave instituted a number of strategies to make this transition acceptable and more beneficial for the patients.One of the strategies that we used is an Advanced Care Plan. By having a consultation at the time when thepatient is diagnosed, we are able to speak with them about what it is that they see in terms of what would beacceptable to them. We use the Project Grace Advance Care Plan which was developed by a physician and isvery simple to understand. With this tool, we are able to bring up the discussion while trying to focus in on thepatient’s spirituality and the coping mechanism as the cancer patient. This allows the conversation of end of lifetreatment preferences and what the patient’s typical desire is for life sustaining measures.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20102325http://journal.waocp.org/article_25163_4a5a3d696e7776507e3d718fedb25aa3.pdfClinical Aspects of Pharmacogenetics of Pain and Co-Morbidities of Emotional Distresstextarticle2010engThe majority of patients treated for cancer will have pain at some point in their journey. It will be due to thedisease (e.g. bone metastasis, fracture, organ invasion) or from iatrogenic causes (chemotherapy, surgery orradiation). A large number of patients will also have depression. Since pain and depression share commonbiological pathways and even neuro-transmitters it is not surprising that a comorbidity of pain is depression. Ithas already been reported that patients in severe pain are 4 times less likely to respond to therapy for depression.In recent years, especially in the era of molecular biology and post-genomic a wealth of data in the arena ofpharmacogenetics/genomics has shed more light on cancer related symptoms such as pain and related them tothe cytokine pathways, especially the interleukins and tumor necrosis factor (TNF). When we remember thatthe synonym for TNF is ‘cachectin’ it is no wonder patients feel awful when there is active disease and the bodytrying to mount a response. Neuroendocrine, immunomodulatory and inflammatory pathways are likelyimportant in the pathophysiology of pain and depression. These realizations are in addition to a greaterunderstanding of afferent pathways for pain perception, of the multiple opioid receptors, the effects of hormonesand catechol metabolism and other transmitters. Moreover we already have a more complete under-standing ofdrug metabolism, especially of the opioids, the back bone of all pain treatment. There are a number of singlenucleotide polymorphisms (SNPs) in the genes important for drug metabolism such as CYP2D6, a cytochromeresponsible for about 25% of all drugs. There are about 90 variants already reported and rapid and slowmetabolizers need very different doses of codeine or morphine. We are entering an era of having the capabilityto develop personalized treatment for our patients’ nociceptive pain, neuropathic pain and depression. Theconvergence of new knowledge in the molecular biology and pharmacogenetic era should allow us to treat ourpatients’ suffering with a resultant increased quality of life even while we strive to cure them of their malignancy.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20102730http://journal.waocp.org/article_25164_3f3f5e24ee5332e21c1d1607cc2c28fb.pdfSpiritual Pain and Sufferingtextarticle2010engSpiritual pain/suffering is commonly experienced by persons with life-limiting illness and their families.Physical pain itself can be exacerbated by non-physical causes such as fear, anxiety, grief, unresolved guilt,depression and unmet spiritual meets. Likewise, the inability to manage physical pain well can be due to emotionaland spiritual needs. This is why a holistic, interdisciplinary assessment of pain and suffering is required for eachpatient and family. The mind, body and spirit are understood in relationship to each other and, in those cases, inrelationship to a deity or deities are important to understand. Cultural interpretations of pain and sufferingmay conflict with the goals of palliative care. Understanding the spiritual framework of the patient and familycan help to assure that the physical and spiritual suffering of the patient can be eliminated to provide a peacefuldeath. Spiritual practices may help in the management of physical pain.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20103136http://journal.waocp.org/article_25165_280a3924b97baab094639fbfe0f69001.pdfPractical Aspects to Spiritual Paintextarticle2010engSpiritual pain/suffering is commonly experienced by persons with life-limiting illness and their families.Physical pain itself can be exacerbated by non-physical causes such as fear, anxiety, grief, unresolved guilt,depression and unmet spiritual meets. Likewise, the inability to manage physical pain well can be due to emotionaland spiritual needs. This is why a holistic, interdisciplinary assessment of pain and suffering is required for eachpatient and family. The mind, body and spirit are understood in relationship to each other and, in those cases, inrelationship to a deity or deities are important to understand. Cultural interpretations of pain and sufferingmay conflict with the goals of palliative care. Understanding the spiritual framework of the patient and familycan help to assure that the physical and spiritual suffering of the patient can be eliminated to provide a peacefuldeath. Spiritual practices may help in the management of physical pain.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20103739http://journal.waocp.org/article_25166_4ff8845fcc98d8c44893ae0a09ab2d1c.pdfBeyond Quality of Life: the Meaning of Death and Suffering in Palliative Caretextarticle2010engThe majority of patients treated for cancer will have pain at some point in their journey. Suffering and deathare common events in cancer patients. Palliative care has been very successful in reducing the discomfortcaused by physical pain, but does not have the means to address the questions related to the meaning of sufferingand death. The soothing of physical pain has helped highlighting other forms of pain, such as spiritual andexistential pain, that uniformly accompany the terminal phase of the disease. Health care providers should beable to identify existential and spiritual pain for several reasons. First, because misdiagnosing these conditionsmay lead to inappropriate use of opioids and sedatives and may deprive both the patient and the patient’sfamily of the experience of death as an essential and irreplaceable experience of life. Second, because spiritualand existential pain may be addressed by properly trained professionals that should be involved in themanagement of the patients when needed. Chaplains and spiritual directors have no lesser role in the managementof a patient than a cardiologist, a surgeon or a psychiatrist. Third because clinical scientists cannot close theireyes in front of one of the most common human experiences falling under their domain. Lack of training and offull understanding is a lame excuse for skirting the suffering of a person dying under our eyes. Health careproviders unwilling or unable to abandon their areas of comfort and to embrace new and risky experiences area liability for themselves, for their patients, and for the society they serve. Both spiritual and existential painaddress the basic questions of human consciousness: while are we alive? Why do we die? Spiritual pain is mostcommonly experienced by a person who has a religious or otherwise sense of transcendence and may be helpedby a hospital care trained chaplain. Existential pain is more typical of a person uninterested in a transcendentcontext and may be more challenging to address in the health care context. Though both may produce emotionalpain, neither is by itself a form of emotional pain and cannot be fully cared for by a counselor. The clinicaldefinition of spiritual and existential pain is evolving and so is its treatment. Classical clinical trials have little tooffer for these conditions. Qualitative research in its various forms, including open ended questions, contentanalysis and mainly personal narrative are the most promising forms of research to comprehend spiritual andexistential pain.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20104144http://journal.waocp.org/article_25167_de77705e0ecf0a4be14304ab693241e1.pdfReligion, Medicine and Spirituality: What We Know, What We Don’t Know and What We Dotextarticle2010engReligion and spirituality have been linked to medicine and to healing for centuries. However, in the early1900’s the Flexner report noted that there was no place for religion in medicine; that medicine was strictly ascientific field, not a theological or philosophical one. In the mid to the latter 1900’s there were several laymovements that started emphasized the importance of religion, spirituality and medicine. Lay religious movementsfound spiritual practices and beliefs to be important in how people cope with suffering and find inner healingeven in the midst of incurable illness. The rise of Complementary and Alternative Medicine as well as theHospice movements also influenced attention on the spiritual aspect of medicine. The Hospice movement, foundedby Dr. Cecily Saunders, described the concept of "total pain"--- i.e. the biopsychosocial and spiritual aspects ofpain and suffering. Since the 1960’s there has been increased research done in the area of religion and healthand spirituality and health. Most of the studies are association studies which demonstrate and association ofreligious or spiritual beliefs and practices and some healthcare outcomes. More recently, studies on meditationhave demonstrated significant improvement in health care outcomes and suggest meditation as a therapeuticmodality. There are also numerous surveys that demonstrate patient need for having spirituality integrated intotheir care. Finally, a recent study demonstrated that patients with advanced illness who have spiritual care havebetter quality of life, increased utilization of hospice and less aggressive care at the end of life. In spite of all thesestudies, we still do not have a biological evidence base for mechanisms of beliefs and practices. There is considerablecontroversy over whether spirituality and religion can or even should be measured as criteria for integrationinto clinical care. Many believe that healthcare professionals have an ethical obligation to attend to all dimensionsof a person’s suffering, including the psychosocial as well as the spiritual and that ethical obligation is sufficientto require integration of spirituality into clinical care. Over the last twenty years, there has been an increase inthe number of required courses in spirituality and medicine in US medical schools giving rise to a new field ofmedicine. In February of 2009, a national consensus conference developed spiritual care guidelines forinterprofessional clinical spiritual care. These guidelines as well as the educational advances, research andethical principles have supported the newly developing field of spirituality and health.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20104549http://journal.waocp.org/article_25168_5f356898f1e24f35a54c60540494d6de.pdfFormal and Informal Spiritual Assessmenttextarticle2010engSpirituality is increasingly recognized as an essential element of health. A novel model of interprofessionalspiritual care was developed by a national consensus conference of experts in spiritual care and palliative care.Integral to this model is a spiritual screening, history or assessment as part of the routine history of patients.Spiritual screening can be done by a clinician on an intake into a hospital setting. Clinicians who make diagnosisand assessments and plans, and make referrals to appropriate experts do spiritual histories. In spiritual care,board certified chaplains, spiritual directors and pastoral counselors are the typical spiritual care referrals.Board certified chaplain do a spiritual assessment that is a more detailed assessment of religious and spiritualbeliefs and how those impact care or patient’s healthcare decision-making. There are several screening andhistory tools. One history tool named FICA, was developed by a group of primary care physicians and recentlyvalidated at study at the City of Hope. This tool is widely used in a variety of clinical settings in the US andCanada. The spiritual history tools allow the clinician the opportunity to diagnose spiritual distress or identifypatients’ spiritual resources of strength and then integrate that information into the clinical treatment or careplan.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20105157http://journal.waocp.org/article_25169_790c31354dc2697980a3e61c980ae950.pdfMy Illness, Myself: On the Secrecy of Shametextarticle2010engResearch has shown that the experience of being diagnosed with cancer has a negative psychosocial impacton patients and their families, often resulting in distress, and numerous practical and relationship challenges.Men with prostate cancer and their partners face special challenges. A range of symptoms that result frommonitoring patients and side effects of treatment may reverse the quality of life and intimate relations betweenpatient and partner. However, patients often are reluctant to bring up their distress about the symptoms, leadingto an underestimation and reduction in optimal symptom control. As a result of their illness, chronically-illmale patients often experience elevated levels of stress, daily activities are often limited, they are frustratedabout the unpredictable course of the illness and its symptoms, and are immersed in fears about their presentand future social identity. Most of them avoid disclosure about their illness – when and where possible - andplace great importance on sustaining a normal life. Factors related to limiting disclosure include men’s lowperceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping,practical necessities in the workplace, and the desire to avoid burdening others. This paper contributes to anunderstanding of the complex issues of disclosure related to prostate cancer patients and raises issues about howbest to be helpful, within their cultural and social framework. It also deals with feelings of shame, guilt andinadequacy as the cause – or consequence – of concealing the illness. The oral presentation will use a clinicalexample of secrecy and the subsequent conflicts and quandaries of a religious person diagnosed with advancedprostate cancer. Dilemmas of shame, disclosure and guilt will be the focus of the discussion.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20105962http://journal.waocp.org/article_25170_3b40a276884f3f11d82eb6970d5b846e.pdfBeyond Pain: The Search for Hope in the Patients Journeytextarticle2010engHope is the foundation of the cancer patients world and it is when the darkness is most profound that hopeemerges as the true reality. Hope remains the patients inner strength, a dynamism that grows more powerfuleven as the physical body weakens. We humans are always hoping for something and The Hope System addressesall levels of the entire cancer experience: physical, emotional, psychological and spiritual. By systematicallylearning how to recognize and honor patients hopes, each of us can support him/her from first diagnosis to lastbreath in a way that is healing and positive for all. Utilizing this simple, powerful tool enables us to tap into thepatient’s ever changing reality, the role hope plays in one’s life while confronting one’s mortality, and be able tolisten, hear and accompany them each step on their final life into death journey.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20106366http://journal.waocp.org/article_25171_7396fd2454fc5e97496e3d6d380ff082.pdfBring about Benefit, Forestall Harm: What Communication Studies Says About Spirituality and Cancer Caretextarticle2010engTechnological advances in medicine allow health care providers to diagnose diseases earlier, diminish suffering,and prolong life. These advances, although widely revered for changing the face of cancer care, come at a costfor patients, families, and even health care providers. One widely cited consequence of better diagnostics andimproved treatment regiments is the sense that there is always one more test or therapy available to extend life.Such an approach to cancer care can prove detrimental to patients’ healing. In addition, these new tests andtreatments further focus attention on the body as the site of healing and cure while downplaying other aspects ofhealth. The absence of psychological, social, and spiritual care from a patient’s cancer care plan compromiseshealing and makes palliative and end of life care more complicated. In this essay, I discuss the tensions that existbetween contemporary cancer care and spirituality and use Communication Studies scholarship to navigate thechallenges of integrating a patient’s religious or spiritual beliefs into their cancer treatment and care. In additionto discussing the challenges of communicating about sensitive topics such as illness, spirituality, and dying, thisarticle uses narrative examples from a comprehensive cancer center and a hospice (both in the United States) tounderstand how people with cancer and other terminal illnesses communicate their spirituality and how theseconversations influence health care choices and provide comfort. By understanding how patients communicateabout topics such as the meaning of life, quality of life, dying and death, providers are better equipped to offercare that is consistent with a patient’s beliefs and life goals. This approach maintains that communication ismore than a means of transferring information, but is constitutive. By understanding that communication createsour lives and shapes our worlds, lay and professional caregivers can meet patients where they are spiritually,emotionally, and socially and offer effective care that is culturally situated. For many in Muslim societies, acancer diagnosis is Divine fate. Understanding a cancer diagnosis as destiny offers comfort to some, yet cancerpatients and their family members may experience isolation because of the stigmas associated with the disease.This double-bind can lead to spiritual or existential crises, which draws further attention to the need for effectivespiritual care that ultimately fosters patient and family healing whether or not a cure is possible. Bringingtogether various approaches to communicating about diverse spiritual and religious ideas may allow for enhancedcomprehensive cancer care.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20106773http://journal.waocp.org/article_25172_2090e20639d274cb5f41ab1d6f39efd4.pdfResearching the Meaning of Life:Finding New Sources of Hopetextarticle2010engThe purpose of the paper is to discuss means of assisting terminally ill patients in seeking for sources ofmeaning and hope, alongside the acknowledgment that their lifespan is short.Psycho-spiritual aspects make asubstantial component patients suffering from incurable illness have to deal with. Evaluating and mapping thecauses and expressions of psychological - spiritual suffering may assist in tailoring appropriate strategies ofdistress relief. Therefore, interventions should be given in accordance with their specific focus of difficulties, aswell as with wishes and needs. Appropriate interventions in palliative psychotherapeutic rapport are inspiredby identifying new sources for meaning in current life (sometimes, aided by past experiences or future visions).Reinforcing sources for meaning may attempt in providing patients amongst: - Equilibrium, between sufferingand sorrow (which sometimes take over the patient's world), and on the other hand, new experiences, sense ofsatisfaction and fulfillment. Individual's acknowledgment that he is not completely withdrawn from the circleof life, and yet significance and fulfillment in life still exists. For a holistic meaning – centered intervention it isadvisable to simultaneously integrate two central axes: the existential analysis, inspired by concepts drivenfrom Frenkl’s Logotherapy, such as freedom of choice, personal responsibility, inner truth, hope andtranscendentalism; the operative axis, enhancing meaning and hope by assisting patient’s wishes come true.Patients are aware, many times, that those wishes may be their last one, therefore perceive their fulfillment ascrucial for their sense of meaning. Moreover, those wishes may elevate patient and family’s spirit and reducerisk of demoralization. Whereas existential – spiritual interventions are recommended to be given by qualifiedprofessional therapists, the operation of fulfilling wishes is feasible by everyone, from family members to multidisciplinarystaff. Case illustrations for meaning - centered interventions will be discussed in the course of thepaper. Cultural and traditional differences within the Israeli society, expressed in themes of work with patients,will lead to the conclusion, that there are many creative ways for researching meaning of life and sources forhope.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20107578http://journal.waocp.org/article_25173_2c5e584fb03e66ea5ee937461768fef9.pdfHistorical Perspectives and Trends in the Management of Pain for Cancer Patients in Omantextarticle2010engIntroduction. Sultanate of Oman is the second largest country in the Gulf, with a population of 2,867,428 (2008) of which 35.2% is under 15 years and only 3.7% above 65 years. Incidence of newly diagnosed cancers is also the second highest in the Gulf with 11%. Research conducted between 1997-2007 revealed that the most frequent cancers in males: stomach 10%, non-Hodgkins lymphoma 8.6% and prostate 7% while in females: breast 18.9%, thyroid 8.3% and cervix uteri 6.5%. A population-based registry was established in 1996 to compile an accurate database and monitor cancer trends. There is a rigorous follow up of reported cases. Unfortunately most patients report at the hospitals in advanced stages which complicate pain management. All treatment modalities of cancer are available in Oman at the two centers, Royal Hospital and SQUH. There is a continuous effort to develop national educational guidelines, protocols for cancer treatment, palliative care and pain management (PM). Historical Perspectives and Trends in the Management of Pain. In 1970s Omanis used traditional medicine, wassam (moxibustion), to treat pain. In 1988 severe pain was treated in hospitals with intramuscular opioid, whenever necessary (PRN). 1989 SQUH approved use of both parenteral and oral narcotics, received its first consignment, and started PM. The Ministry of Health (MOH) was concerned with possible misuse and for 8 years, thereafter, SQUH was the only hospital allowed to import, stock, prescribe and dispense oral narcotics. Legal requirement to obtain opioids in Oman involves MOH and World Health Organization (WHO) and there is a control as to who can prescribe for both inpatient and outpatient. The drugs available to control pain include non opioids, weak opioids, but the only strong opioids used for severe cancer pain are morphine and Fentanyl. This is complemented with adjuvant drugs. We use the "WHO Ladder" to guide us in the management of pain. Three different cases have been presented to see how PM of cancer patients has evolved from using only non-opioid in 1993, to using intramuscular pethidine in 1995, then to using morphine with adjuvants in 1999. Referral of patients to the PM Team has improved the pain control and at present even without referral, pain is controlled more effectively. Conclusion. There is no doubt that the Sultanate of Oman has progressed tremendously since 1970. The Government is working very hard and is taking major steps to improve cancer care in order to meet the International Bench Mark. Each 5 year plan focuses on actual needs. One of the important needs that have been addressed is the management of pain which has significantly improved. Factors that have improved PM in Oman include the introduction of the PM Teams, training of Nurses and Doctors, follow up of the PM services in the clinical areas, authorizing MOH hospitals to use oral opioids, opening of the National Oncology Centre with Radiation Therapy, inter institutional discussions and development of guidelines, implementation of WHO Guidelines on PM and audits, peer reviews and research.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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20109396http://journal.waocp.org/article_25174_fd1ad65d2d0112acfaab38265c37810c.pdfPain Relief as a Human Righttextarticle2010engFor centuries, medical and surgical treatment has emphasized saving the life of the patient rather thanameliorating the patient’s pain, particularly when there were few options for the latter. Today at the dawn of the21st century, the best available evidence indicates a major gap between an increasingly understanding of thepathophysiology of pain and widespread inadequacy of its treatment. Epidemiologic evidence has proven thatchronic pain is a widespread public health issue. Studies of cancer patients’ pain control consistently reveal thatup to half of patients receive inadequate analgesia and 30% do not receive appropriate drugs for their pain.Equally, for patients suffering HIV/AIDS, 60%-100% will experience pain at some stage in their illness. In thedeveloped world, this gap has prompted a series of declarations and actions by national and international bodiesadvocating better pain control. One response to the worldwide undertreatment of pain has been to promote theconcept that pain relief is a public health issue of such critical importance as to constitute an internationalimperative and fundamental human right. The importance of pain relief as the core of the medical ethic is clear.Pain clinicians promote the status of pain management beyond that of appropriate clinical practice or even anethic of good medicine. They advocate a paradigm shift in the medical professions’ perspective on painmanagement, from simply good practice to an imperative founded on patient rights. There is a need to promotepolicies which create conditions where human beings can bear even incurable illnesses and death in a dignifiedmanner. This must help health professionals or lay groups to initiate a powerful agenda to reform local statutes.The essential components of such legislation are: 1. Reasonable pain management is a right. 2. Doctors have aduty to listen to and reasonably respond to a patient’s report of pain. 3. Provision of necessary pain relief isimmune from potential legal liability. 4. Doctors who are notable or willing to ensure adequate analgesia mustrefer to a colleague who has this expertise. 5. Pain management must be a compulsory component of continuingmedical education. For too long, pain and its management have been prisoners of myth, irrationality, ignorance,and cultural bias. We are confident that the Pain Relief and Palliative Care Working Group under the auspicesof the Lebanese Cancer Society is the main promoter of Palliative Care in Lebanon whose main goal is to relievesuffering and improve quality of life of the cancer patients, and advocate pain relief as a human right.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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201097101http://journal.waocp.org/article_25175_1f34fdfce1622595051052b14f6722c3.pdfAssessment of Pain Coping Behaviors: An Experience of Saudi Advanced Cancer Patientstextarticle2010engBackground: Cancer is one of the major health problems thoughout the world. The number of cancer patientsis increasing, out of the estimated nine million new cancer cases every year, more than half are in developingcountries. The majority of these patients are incurable by the time their disease is diagnosed. Therefore, cancermortality is expected to continue to rise in those regions of the world (WHO, 2002). In Saudi Arabia, the latestreport from the Saudi Cancer Registry SCR for 2004 registered 9,381 new cases, of these cases 7,138 wereSaudis. The crude incidence rate CIR of all cancers among Saudis was 41.9/100,000. The total number of adultcancer incidence cases reported was 8595, and for children were 713 cases (NCR, 2004). The most commonfeared symptom encountered in advanced cancer is pain. Through their perpetual encounter with pain, advancedcancer patients usually maintain different coping behaviors. Internationally speaking, there are limited researchesand investigations that deal with cancer pain, and the importance of using adaptive coping behaviors to controlit. In Saudi Arabia, specifically, pain coping behaviors has never been assessed or discussed before, so is theimpact of cancer pain on the quality of life. The presence of any maladaptive coping behaviors with cancer painwill interfere with the patient's life style and their quality of life, and will affect the nurse's role in caring,planning, and implementing effective nursing interventions to reduce and control cancer patient's pain. Materialsand Methods: A descriptive design was used for this study to assess the pain coping behavior Among Saudipatients suffering from advanced cancer. The study was conducted at the two tumor centers which deal withcancer patients in Jeddah City. A convenient sample of 132 patients with advanced cancer who were returningto the clinics, radiation therapy and medical oncology departments of the aforementioned tumor centers wereincluded in the study. Data were collected by an interview schedule specially designed for this study, and thetime ranged between 20-40 minutes. Tool's content validity and reliability were checked and established at 89%and 85%, respectively. Administrative approval from the two tumor centers in Jeddah City was obtained forstudy conduction. Different statistical methods were used for data analysis and interpretation to specify thevalue of correlation between study variables using SPSS v 10. Results: Patients age were almost equallydistributed among thirties (22%), forties (24.2%), fifties (20.5%), and sixties (22.7%). Females (59.1%) wereslightly more than males (40.9%). About one half (47%) of them were diagnosed since one - two years age, andslightly more than half (56.8%) of them were unaware of their diagnosis. The major adaptive and Active paincoping behaviors included: religious practices such as: praying (99.2%); and listening or reciting the HolyQura'an (98.5%). Cognitive methods such as: thinking that one is more stronger than the pain (99.2%); thinkingthat one is still in a satisfactory health despite the pain (98.5%); distracting oneself from pain (93.9%); visualizationof pleasant scenes (92.4%); thinking about pleasant things (90.9%). The major maladaptive and passive paincoping behaviors included: decreasing activities by: specified positioning (97.7%); protecting the painful area(90.9%); and remaining still and avoiding movement (78%). Expression of feelings by: seeking help from others(90.2%); and crying or moaning (80.3%). Suppression of feelings and tolerating pain as it is (97%). Conclusions:Most of the adaptive and active pain coping behaviors were coming from patient's belief in god & their faith andtrust and holding and obeying Islamic commands. The informational support by the health care professionalswas unprovidable in the study sample, which brings the attention to the importance of nursing interventions inthis area by providing coordinated and directed programs.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010103106http://journal.waocp.org/article_25176_eefa8ce7fffac9e8d163ccc5c1bcccdb.pdfEthical Dilemmas and the Dying Muslim Patienttextarticle2010engAll health care providers may be confronted by a Muslim patient, but many health care professionals arelacking basic knowledge on the Muslim faith and medical ethics based on Islamic law (Shariah). One mustendeavour to differentiate between ethnic customs and Islamic tradition. It is important for staff to have ageneral understanding of the principles of Islamic beliefs and actions to attain better cultural competency andimproved patient care. Terminally ill cancer patients are vulnerable and require sensitive care of their physical,psycho-social, cultural and spiritual aspects and needs. Muslims believe that the purpose of life is a test fromGod with the objective of full obedience, the outcome being purification of the soul and the resultant judgmentafter life to be directed to heaven or hell. The Muslim goal is to live and die in accordance with God’s will, asrevealed in the Qur’an and practiced by the Prophet.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010107112http://journal.waocp.org/article_25177_6c0346b0812082856f5b03f798f5afc3.pdfPsychiatric Aspects of Pain in Cancer Patientstextarticle2010engThe goal of this review is to discuss the psychiatric aspects of pain in cancer patients from a biopsychosocialapproach. Pain in cancer patients is considered as a complex reaction causing severe suffering and involvesmany psychological aspects. It has many dimensions such as personality, affect, cognition and social relations.The pain experience may also be influenced by some psychological factors such as anxiety, depression and themeaning of pain. Therefore, a successful management of cancer pain requires a multidisciplinary approach.Since cancer pain is generally treated medically, the psychological impact of pain is often underestimated.However, cancer pain is usually related to high levels of psychological distress. Culture, as an important factoraffecting cancer pain, will also be discussed during this review. It is crucial to understand cultural diversity inthe treatment of cancer patients with pain. Research shows that a minority patients of various ethnicities haveless control of their pain because of the miscommunication problem within the medical setting. By paying attentionto patients’ cultural diversities, problems such as miscommunication causing inadequate control of pain can beeliminated. In order to manage pain in cancer patients, cognitive-behavioral interventions may be integratedwith pharmacotherapy. The main goal of these strategies is to provide a sense of control and better coping skillsto deal with cancer. Patients’ maladaptive thoughts or behaviors may cause physical and emotional stress. Mainbehavioral strategies include biofeedback, relaxation training, and hypnosis. Cognitive strategies include guidedimagery, distraction, thought monitoring and problem solving. By discussing all of these aspects of cancer pain,the multidimensional characteristic of pain and the relation between cancer pain and psychiatric factors will beclarified.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010113116http://journal.waocp.org/article_25178_b8c9edf538d80118da898200516e2f14.pdfDepression and Pain in Persons with Cancer: Treatment Gap and a Case for Actiontextarticle2010engThe epidemiology of depression showed that the rates are high. For example, the World Mental HealthSurvey, an epidemiologic community study conducted in 28 countries, found a life-time prevalence rate thatranged from 3.3 % in Nigeria to 21.4% % in the US. With regard to persons with cancer, 12.5% of a sample ofover 17,000 respondents over the age of 50 of a US survey of community-dwelling adults found that people thatreported they had cancer had higher risk of fatigue (OR =1.5 95% CI 1.3-1.6); depression (OR=1.2, 95% CI 1.1-1.4) and pain (OR =1.2, 95% CI 1.03-1.3.).The rate of depression seems to be differently associated with cancersite. For example: It is higher in pancreatic cancer (33%-50%) and lung (11%-44%), and it is lower in lymphoma(8%-19%) and colon (13% and 25%). For breast cancer –likely the most studied cancer site- the prevalenceranges from 1.5% to 46%. Ciaramelli and Poli (2001) found that depressed persons had more pain and metastasisthan the non-depressed but no more lifetime depression that the non-depressed. In terminally patients, studieshave found that the higher the level of disability the higher the rates of depression. Interestingly, while almost allstudies of depression in the community found higher rates in women than in men - this is far from the ruleamong persons with cancer. Despite the marked burden and the existence of effective treatment, a very largeproportion of the persons with depression remain untreated. The causes to be imputed for the treatment gapare of different nature. Some of these causes are related to the suffering person, to the social context and to thehealth system. Often, the treating physicians fail to identify depression and to treat it properly. For example, inone evaluation of 456 outpatients with solid tumors a minority (14%) of the depressed were identified as such.Why is it important to assess depression in persons with cancer? Untreated depression both enhances the risksto life and it lowers the quality of life. It may be associated to a reduced chance of survival in women with earlystage breast cancer. One possible reason is limited adherence to the treatment plan. Timely identification andwell prescribed and conducted treatment could make a substantial difference.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010117119http://journal.waocp.org/article_25179_735b1531e6f566ab8a95243a78abd713.pdfSelected Issues in Palliative Care among East Jerusalem Arab Residentstextarticle2010engUnderstanding of cultural context is important when working with Palestinian patients, particularly in Israelihospitals. Cultural competence includes individual assessment of communication needs and preferences. "Thisis God’s will and one mustn’t protest. A person who believes accepts all that God gives”(patient quote).Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811

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2010121123http://journal.waocp.org/article_25180_ed9ce04eea30d0e96540a32919aaf8b8.pdfSurprised by Joy: a Journey through Sufferingtextarticle2010engUnderstanding suffering as possible meaning of cancer for patients and their families is a necessary part of cancer nursing care. Suffering occurs when the intactness or integrity of the individuals is threatened or disrupted (Cassel 1999); the authors believe that exploring cancer patients' suffering is vital to improve patient quality care. This article discusses suffering as a feature for oncology patients at tertiary hospital in Jordan. We are aiming through understanding the three following narratives of cancer patients who experience and witness thesuffer during their disease journey to illustrate how the suffering reflect their behavior and day to day life. The first case is a young man of 24 years old who was diagnosed with nasopharyngeal carcinoma five years ago, treated then relapsed and receiving palliative care up to moment, the narrative focus on his suffering from corrupted relations with his wife due to infected face wound and loss of the financial support. The Second case is a 38 years old female who diagnosed with melanoma 15 years ago, she experience psychological suffering due to changes in her body image. She is taking care of motor handicapped husband in addition to her Kids. The Last case is a 54 years old female who had lung cancer. She is still fighting her disease. Consequently, she is suffering from the disease, cause to affect her job.We found out that their spirituality and beliefs system enables them to endure and fight their disease, alleviate suffering, enhance adaptation and redefine hope. The health care team who provide the care for these cases focus interdisciplinary team approach who affirm that thetranscendental is there when disease and mute or expressive suffering are recognized together, they do the work of creating a full meaning for patients and families. Nurses play a crucial role in managing such cases .It is the core of nursing care to presence the mean of listening, touching, acknowledging, honoring patient’s wishes and working within specialized multidisciplinary team, It is the greatness to be part of a team that being a huge circle surrounding patient with special demand and focusing on them in addition to their families rather thanthe disease itself aiming to assure best quality of life and to gain patients satisfaction. They recognize, assess and reassess patients’ needs reframing of goals by educating, advocating, coordinating and supporting, with themajor role in bereavement.Asian Pacific Journal of Cancer PreventionWest Asia Organization for Cancer Prevention (WAOCP)1513-736811